HomeMy WebLinkAboutBLD99-0442 Remodel - BLD Application - 5/24/1999 a
PERMIT NO.: BLD
MASON COUNTY 5
BUILDING PERMIT APPLICATION
426 W.Cedar/P.O.Box 186,Shelton,WA 98584
Shelton 360 427-9670 Belfair 360 275-4467 Elma 360 482-5269 Seattle 206 464-6968
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner S i S P U S S L- Contractor Name
Mailing Address ?,)"�r O C /-/A-) /O Mailing Address
City v•U/O 6 State A?Z Zip Code City State Zip Code
Phone 60 X,Z36 Zther Ph.( ) Ph.( Other Ph.(
Lien/Title Holder /VD uL'' Contractor Reg. #
Address Expiration
SEPTIC/WATER SYSTEM INFORMATION-Connect to New Septic Existing Septic Connect to Sewer
System Name of Sewer System Well �'' Water System Name of
Water System T A i/ /1 U- S L/
PARCEL INFORMATI y2 digit Tax arcel l l 0G'G� Fire District
Legal Description � h✓z LOT /
Site Address(Please inc ude street name, street num and city)
Directions to site If 14 S ? NIL F L D `rt oz9llc
Will timber be cut and sold in parce es/No)
Is your property within 200' of th owing: Body o alterN Saltwater
Lake River/Creek pond Wetlan off Stream Slopes or
Bluffs
L�!j
TYPE OF JOB Ne Add Alt Repair r U�� ldin „� �H
Describe Work C,/n ��� k5f r
No. of Bedrooms No. o throornS ARE F TAGE-1st Floor 2nd Floor
3rd Floor Loft asem Other sq. ft.
Garage Attached D hed Carpo 4ached Detach
MOBILE HOME INFORMATION-Make el Mod\ear
Length Width Serial No. No. of B ms throoms
Type of Heat Purchase Pri e epI t Un )
Installer Name Certi n
NOTICE: THIS PERMIT BECOMES NULL&VOID IF WORK OR CON UCTION AUTH IZED IS NOT COM CED WITHIN 1 AYS OR IF
CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PER OF 180 DAYS NY TIM WORK IS CO ENCED.
PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS I CTION. Theo er o gen owne ehalf,repres is that the
information provided is accurate and grants employees of Mason County ac s to the above de ribed pro an lures for iew and
inspection of this project. Acknowledgment of such is by signature below:
OWNER AFFIDAVIT-I certify that I am exempt from the requirements of the CONTRA R'S AFFIDAVIT- ify that I am cur istered as
Contractor Registration Law RCW 18.27 and am aware of the ordinance contractor in t State of Washington and th ware of the ordinance
requirements for which this permit is issued ad that all work will be done in requirements re ting the work for which s permit is issued and all work
1;
confor ce therewith. No pI15nges shall be'ade without first obtaining shall be done in co mance therewith. changes shall be made without
val. first obtaining approval
Date 3� Z 47 X Date
Am
FOR OFFICIAL USE BEYOND THIS POIN
Accepted by Date Submittal Amount Due Receipt No.
P P
DEPARTMRNTAL REVIEW APPROVED DENIED CONDITJXN CODES
Building Department
Occ Group Type Constr.
Planning Department
Environmental Health Department
Public Works Department
I
Fire Marshal
Valuation $
FEES
Building Permit Fee Site Inspection
Plan Review Fee UFC Plan Review Fee
Plumbing & Base Fee Public Works Review Fee
Mechanical & Base Fee Other
Wood/Gas/Pellet Stove Fee Other
Violation Fee Pre-Paid at Submittal ( )
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